All prescribing conversations should feel like a person centred conversation, says Anya de Iongh
The semantics of healthcare is a never ending source of discussion, providing both fascination and frustration in equal measure. The rising profile of “social prescribing” has not escaped the common nomenclature debate.
As the wider social determinants of health and non-medical issues such as loneliness (and their impacts) are more recognised, prescribing non-clinical options like gardening groups, walking groups, and community support are being considered alongside pharmacological prescriptions. It is a core part of the model for personalised care being championed by NHS England, and happens across a number of innovative services across the country.
The principles of connecting people with community based sources of support is only to be welcomed, but the branding of this process as “prescribing” has caused some debate.
It is clear that there are medical connotations with the phrase “prescribing.” On the one hand, these medical connotations can help this non-clinical approach gain traction among a clinical workforce—something much needed if this is to be embedded and integrated within primary care for example. On the other hand, this medicalisation can lead to inappropriate and unjustified labelling of normal aspects of humanity, and overlook the role of communities and the community based principles of social support.
I’m interested in how the reasons put forward for the latter—that we don’t want the person centred nature of connecting people with social support to be contaminated by the medical approach of “prescribing”—make assumptions about the process of prescribing generally.
No matter how successful social prescribing is, the harsh reality is that our NHS will still be making many times more pharmacological prescriptions than social prescriptions. In 2017, there were over 1 billion pharmacological prescriptions (NHS Digital). So rather than trying to find a better word for social prescribing, why not make all “prescriptions” something person centred?
Whether it is warfarin or walking that we are being prescribed, the conversation should be based on the same principles. Prescribing shouldn’t be a “dirty” word, if done well.
The principles of a conversation that results in someone being supported to access non-clinical sources of support have the following key components: starting with the person, what matters to them, having time and space to explore all the options, supporting their confidence to take the next step, and opportunities to follow up and review how it is working. That feels relevant, and should be relevant, whatever we are prescribing.
Reading the guidance on prescribing from NICE/BNF, I was struck by how person centred their definition was: “the prescriber and the patient should agree on the health outcomes that the patient desires and on the strategy for achieving them.” That applies whether we are talking about health outcomes met by a book group or bisoprolol.
There is always a risk that it is used as a proxy—with “pseudo person centred” approaches masking a directive approach to changing people’s behaviour. This was captured in a recent comment from the health secretary, Matt Hancock, “anybody can suggest to somebody that they do a social activity. My wife regularly tells me to do more exercise.” I don’t know whether exercise is personally important to Mr Hancock or not, but I do know that “telling people to do things” doesn’t feature as part of social prescribing as I understand it. We already know that telling people to take medications probably isn’t that effective either. This strikes me as an opportunity to share learning and skills around developing shared understandings, exploring confidence to follow through, and supporting people to take ownership.
Shared decision making and co-production apply whether we are prescribing citalopram or coffee mornings and gardening or gabapentin. All prescribing conversations should feel like a person centred conversation.
Prescribing isn’t just about the conversation though, it is also about the resources, and herein does lie a considerable difference. Prescribing medications is authorising access to a restricted product, and the physical commodity of tablets is a far cry from the living and breathing communities that form the backbone of social prescribing. Keeping stocks of medications may require temperature controlled storage, but keeping communities thriving requires more than just referrals—asset based approaches and investment are essential.
Anya de Iongh is patient editor for The BMJ and works nationally and locally around person centred workforce development and self-management support services.
Competing interests: Full details here.